Lee Hammontree, MD
"Two days ago, I removed a tumor that was almost half the size of the kidney," says Lee Hammontree, MD, with Urology Centers of Alabama. "We're getting better and better at preserving kidney function by doing partial nephrectomies."
The credit for this latest successful surge of partials goes to the Firefly addition on the da Vinci Surgical System. The da Vinci has been around since 1999 and has been used extensively in many surgical specialties, from cardiac to neurology. It entered the renal cancer arena around 2006.
"Almost every renal mass now, we're trying to look at it with robotic and other techniques and asking, 'Can we do a partial?' And the answer is becoming 'yes' more and more," says Thomas Holley, MD, with Urology Centers of Alabama. He works on the da Vinci primarily out of Trinity Medical Center and St. Vincent's Birmingham.
The Firefly addition arrived on the Birmingham scene in September. "Since the advent of robotic surgery, we've done fewer radical nephrectomies. The Firefly system helps us do an even better job," says Hammontree, who works out of Brookwood Medical Center.
Firefly uses near-infrared imaging to detect an injected dye of indocyanine green (ICG) in the blood. The dye helps identify vascular flow to the kidney and distinguish between normal tissue and cancer tissue. "In the viewer, it looks like a black-light effect. You're seeing everything in black and white, then suddenly bright green shows up where the dye emerges," Hammontree says.
The da Vinci allows the surgeon to toggle between normal laparoscopic viewing and the near-infrared imaging to track the bright green dye.
During the nephrectomies, the urologists utilize the new system at three stages. The first injection of the dye by the anesthesiologist helps identify the arteries leading to the kidney.
"Smaller arteries aren't sometimes appreciated on CTs," Holley says. "Maybe ten to fifteen percent of the time, we find an extra artery that's not been recognized on the pre-op imaging. Firefly is very helpful with finding those."
"In a recent surgery, I found a segmental artery we'd not seen before we had this Firefly access," Hammontree says. "That view prevented us from having unexpected excessive bleeding."
The second injection of dye helps distinguish the normal tissues from the tumor. "Because the blood flow in the tumor is less," Hammontree says.
After the tumor is removed, surgeons inject the dye a final time to ensure the kidney function has fully resumed. "Before this, it was unconfirmed," Hammontree says. "Now we can watch the kidney turn green and then the renal vein turn green and that gives us confirmation that the remaining kidney is functioning properly."
According to Hammontree, 90 percent of nephrectomies were radical 20 years ago. Now partials dominate the stats at 60 to 70 percent, thanks to advances in techniques and especially technologies.
Prior to the robotic surgery system, only radical nephrectomies were done laparoscopically. Partials had to be performed as open surgeries. "The robotic surgery has made partial nephrectomies done with the laparoscopic technique much more manageable and safe," Hammontree says.
"When I was in training five years ago, we were doing pure laparoscopy, and I couldn't do some of the masses I'm doing today," Holley says.
Holley is doing five to ten partial nephrectomies a month now. He says the robotic option allows him to better dissect out arteries and veins and put clamps exactly where he needs them.
"The sliding Weck clip has been around several years, but the robot allows you to easily tension your closure after removing the mass," Holley says. "You can pull up on the stitch and slide the clip down. The force of the tension is spread over the clip, so there's less chance of tearing. It's made it more feasible for more complex closures."
Hammontree is doing two to five cases a week using the da Vinci, including five partials last week using the Firefly. "It's become the biggest part of my practice."
Both agree that the difference between a partial and a radical can be determined as much by the urologist's experience as the technology. "It's lent itself to some specializations in our field, just like with prostate surgery and prosthetics," Hammontree says. "It's even become sub-specialized with technically difficult cases being performed by fewer people."